201 NORTH ST - BUILDING INSPECTION i I
(J The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7ih edition OF SALEM
Revised Jannury
Building Permit Application To Construct,Repair, Renovate Or Demolish a /. 1008
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit N ber: 4 Date Applied: f>' f O
Signature•
Bui Illing Commissio. /In for of Buildings Date
SECTION 1:SITE INFORMATION
I.1 Property Address• 1.2 Assessors Map& Parcel Numbers
_
l a Is this an accepted street?yes V no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.I,c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal O On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
1 Owner of Re ord:
N Q �j P St ear
Nam Print)< Address for Service:
t/bl /a�%Sy70 rem
Si atu Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work'': lQ i -{-
ya�+ -h Ab
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S 1. Building Permit Fee: S Indicate how fee is determined:
2. Electrical
❑Standard City/Town Application Fee
S
❑Total Project Cost(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (11VAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
�•y�-� Check No. Check Amount: Cash Amount:_
6. Total Project Cost: S 25CU 13 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL-Ilolder List CSL Type(see below)
ry PC Description
Address - u Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature M Musionry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or FIIC Registrant Name Registration Number
Address Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ..........❑ No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, ',FeS6iCCA as Owner of the subject property hereby
authorize to act on my behalf,in all matters
-�n::M (7l Oyvt .
relative work authorized by this building permit application.
Si re of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Uate
(Signed under the pains and penalties of perjury)
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will no have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.115, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(Sq.Ft.) habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half'/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
4k CITY OF SALEM
PUBLIC PROPRERTY
' DEPARTMENT
lf\L: IV 5rxl•L'T 0 S.\t 191,fit.\NiAl 111 -
1'171:978.74.5.9:95 • IC%x:978•740-9846
Construction Debris Disposal Affidavit
(required I'ur all denolition;uid renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # _ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
(numc of hauler)
The debris will be disposed of in
(Ilameut aci Ity)
(address4) facility)
.Igl ore of Ixnnit applicant
dam
CITY OF SAL.E.NI
PUBLIC PROPERTY
DEPARTIMENT
MAVIO' 130 WX"AG1O Siam•
c...K�rwQAOlt'SSrtf 019'O
TEL 9'11.704S"• FAx 9711.74&9$46
HOMEOWNER LICENSE EXEMPTION
Pleas. Print
Date
Job Location 2-0 NC7r-kh kS+ �R6,Vl
Home Owner Address 2 D
Home Owner Telephone 1-/0l - .37cs- q LD 70
Present Mailing Address 7 OI fymr+G, 5+ Sa l oyi
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or feat and to allow such homeowners to engage an individual for
hire who,does not possess a license,provided that the owner acts err supervisor.
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on
which there is, or is intended to be, a one or two family divu'slling, attached or detached
structures accessory to such use and/or farm structures. A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official,on a form acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulation.
The undersigned "homeowner"certifies that he/she understands the City of Salem
Building Department minimum i ion procedures and requirements and that he/she
will comply with said procedtues an4 equiremrnts.
HOMEOWNERS SIGNATURE
-4m,
.APPROVAL OF BUILDING INS CTOR
See other side for state code